INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 1-2, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Chartiers Community Mental Health and Retardation Center, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
The findings include:
A physical plant inspection was conducted on February 2, 2016. At the time of the inspection, the door which leads to the secondary exit was found to be locked. The room is currently being used for client record storage. All exits from the nonresidential facility must be unobstructed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
File Cabinets in the area identified for egress during a fire were removed and placed in an alternate location by maintenance staff.
The lock was removed on the internal side of the door to ensure quick exit from the facility in the event of an emergency.
All exists are now unobstructed and egress can occur as required. In the future, all exits will be unobstructed; the Facility Director will be responsible to assure such.
|
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
|
Observations
Based on a review of client records, the facility failed to develop policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
The findings include:
Ten client records were reviewed on February 1-2, 2016. The project's policy and procedure manual was also reviewed on those dates. The project has a policy and procedure in place which includes all of the required client rights; however, the client rights that are being provided to, and acknowledged by clients does not include all of the required client rights. The following client rights were not documented in the orientation/handbook provided to clients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10:
1) A person receiving care or treatment under section 7 of the act, shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
3) A client has the right ot inspect their own records. The project , facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
4) The client has the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All client rights are posted and reviewed upon admission but were not contained in total within the consumer handbook. The Handbook has been revised to include all consumer rights which include:
Consumer rights for consumers participating in the Chartiers Substance Abuse Outpatient services include:
To retain civil rights and liberties as provided by law. No consumer shall be deprived of any civil right solely by reason of treatment. Chartiers Substance Abuse Outpatient Services may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
To be treated with dignity and respect.
To receive medically necessary treatment.
To participate in the development and review of the service plan.
To be assured of confidentiality and privacy in regards to treatment and records as prescribed by law.
To be informed of the fee schedule, determination of fees, hours of operations, after hours contact and contacts in emergency situations.
To be informed of the guidelines for admission, treatment and discharge.
To expect that the Agency practices and settings are reasonably safe.
To receive treatment in the least restrictive setting to permit achievement of treatment goals.
To be discharged from treatment when services are no longer necessary.
To refuse services and be informed of the consequences of this decision.
To submit a written request to review the clinical record.
To inspect his/her record. The program may temporarily remove portions of the records prior to the inspection by the consumer if the Director of Substance Abuse Outpatient Services determines that the information may be detrimental if presented to the consumer. Reasons for removing sections shall be documented in the record. The consumer has the right to appeal a decision limiting access of the record to the director of Substance Abuse Outpatient Services.
To maintain unrestricted and private communication which includes choosing an advocate of choice in the assertion of rights; to see a lawyer in private at any time and to file a complaint and have my complaint heard and responded to in a timely manner.
To request the correction of inaccurate, irrelevant, outdated or incomplete information and/or submit rebuttal data or memoranda to his own records.
Previous versions of the handbook have been destroyed. The handbook with the revised rights is now available for distribution. Going forward, the Facility Director shall be responsible to ensure that client rights are communicated and enforced in the required manner. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in nine of nine client records.
The findings include:
Ten client records were reviewed on February 1-2, 2016. Nine of the clients reviewed were in treatment for a period of time that would require their treatment and rehabilitation plan to be reviewed and updated. Client records # 1, 2, 3, 4, 5, 7, 8, 9 and 10 did not include treatment and rehabilitation plans that were updated at least every 60 days.
Client #1 was admitted on September 17, 2015. A treatment plan review/update was completed on November 10, 2015. The next treatment plan review/update was due to be completed by January 10, 2016. The only other treatment plan review/update was completed on January 19, 2016.
Client #2 was admitted on July 6, 2015. A treatment plan review/update was completed on October 29, 2015. The next treatment plan review/update was due to be completed by December 29, 2015. The only other treatment plan review/update was completed on January 26, 2016.
Client #3 was admitted on July 23, 2015. A treatment plan review/update was completed on September 18, 2015. The next treatment plan review/update was due to be completed by November 18, 2015 and January 18, 2016. The only other treatment plan review/update was completed on November 23, 2015.
Client #4 was admitted on September 16, 2015. The comprehensive treatment and rehabilitation plan was completed on September 16, 2015. The treatment plan review/update was due to be completed by November 16, 2015 and January 16, 2016. The only other treatment plan review/update was completed on December 18, 2015.
Client #5 was admitted on September 11, 2015 and discharged on November 25, 2015. The treatment and rehabilitation plan was completed on September 11, 2015. The treatment plan review/update was due to be completed by November 11, 2015. The only treatment plan review/update was completed on November 24, 2015.
Client #7 was admitted on August 19, 2015 and discharged on January 20 ,2016. A treatment and rehabilitation plan review/ update was completed on September 18, 2015. The treatment plan review/update was due to be completed by November 18, 2015 and January 18, 2016. The only other treatment plan review/update was completed on January 20, 2016.
Client #8 was admitted on September 29, 2015 and discharged on December 4, 2015. The treatment and rehabilitation plan was completed on September 29, 2015. The treatment plan review/update was due to be completed by November 29, 2015. The only treatment plan review/update was completed on December 9, 2015, after the client's discharge.
Client #9 was admitted on August 25, 2015 and discharged on January 25, 2016. A treatment and rehabilitation plan review/ update was completed on October 20, 2015. The treatment plan review/update was due to be completed by December 20, 2015. The only treatment plan review/update was completed on January 25, 2016.
Client #10 was admitted on September 8, 2015 and discharged on January 20, 2016. The treatment and rehabilitation plan was completed on September 8, 2015. The treatment plan review/update was due to be completed by November 8, 2015 and January 8, 2016. The only treatment plan review/update was completed on November 18, 2015.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An ongoing schedule to ensure that Service Plan Reviews occur every 60 days has been implemented by the Facility Director. The Facility Director is responsible to check the schedule to review and ensure timely completion of each review.
In the event that the client does not show for a scheduled appointment so as to complete a Service Plan review, a review of treatment shall be documented in the electronic record by the primary counselor so as to ensure completion within the sixty (60) day time frame.
|